Download DSM-5 and Malingering: a Modest Proposal

Psychol. Inj. and Law
DOI 10.1007/s12207-010-9087-7
DSM-5 and Malingering: a Modest Proposal
David T. R. Berry & Nathaniel W. Nelson
Received: 7 October 2010 / Accepted: 8 October 2010
# Springer Science+Business Media, LLC. 2010
Abstract The DSM criteria for identifying malingering are
reviewed and found to be flawed on both conceptual and
practical grounds. Alternative models for diagnosing
feigned psychiatric, physical, and neuropsychological
symptoms are presented. A number of useful features of
these systems are highlighted for potential contributions to
modified DSM criteria. It is recommended that the present
DSM text on malingering be replaced with feigned
psychiatric, physical, or neuropsychological symptoms
and suggestions for developing criteria for this condition
are made.
Keywords Faking bad . Malingering . DSM
The prospective revision of the Diagnostic and Statistical
Manual of Mental Disorders, 4th Ed., Text Revision
(American Psychiatric Association 2000) is an opportune
time to consider appropriate changes in the nosology. This
manuscript addresses the status of malingering, a V code, or
“other condition that may be a focus of clinical attention”
(American Psychiatric Association 2000, p. 739). At the
time of this writing in August, 2010, there do not appear to
be any moves to revise the DSM text on malingering, based
on review of the APA website. In light of the serious
David T. R. Berry holds the copyright to the Letter Memory Test. All
proceeds from the Letter Memory Test are donated to the Harris
Psychological Services Clinic.
D. T. R. Berry (*)
Department of Psychology, University of Kentucky,
Lexington, KY 40506-0044, USA
e-mail: [email protected]
N. W. Nelson
Minneapolis VA Medical Center and University of Minnesota,
Minneapolis, MN, USA
concerns reviewed below about the conceptual and practical
utility of the directions given in the DSM text for
identifying malingering, it is recommended that this
condition be dropped from DSM-5 and replaced with a
more empirically based alternative.
The term “malinger” appears to emerge from a late
eighteenth century French idiom (malingrer) meaning either
“to suffer” or “pretend to be ill” (Online Etymology
Dictionary 2010). Modern connotations typically reflect only
the latter, more incriminating, and pejorative nuance. In the
current DSM text on malingering, it is defined as “…the
intentional production of false or grossly exaggerated
physical or psychological symptoms, motivated by external
incentives…” (American Psychiatric Association 2000, p.
739). The entry goes on to state that malingering should be
“strongly suspected if any combination of the following is
noted”: medicolegal context of presentation, marked discrepancy between self-reported stress or disability and objective
findings, lack of cooperation during diagnostic evaluation or
with prescribed treatment, or presence of antisocial personality disorder. No further detailed criteria for establishing the
presence of this condition are given in the text.
Conceptual Concerns
There are a number of conceptual issues that bedevil the
text on malingering in the DSM-IV-TR. Like many of the
diagnoses of mental disorders in the DSM, malingering is
presented as a categorical condition. That is, one either is or
is not a malingerer. Recent evidence calls this assumption
into serious question. Walters et al. (2009) reported that
taxometric analyses of results from psychiatric outpatients
completing a health inventory with embedded validity
scales indicated that feigning of physical symptoms was
Psychol. Inj. and Law
dimensional, not categorical. Similarly, Walters et al. (2008)
analyzed Minnesota Multiphasic Personality Inventory 2nd
Edition (MMPI-2) and Structured Inventory of Reported
Symptoms (SIRS) data from forensic neuropsychiatric
evaluees and found evidence for feigned psychiatric
symptoms as a continuous, not a categorical phenomenon.
Finally, Walters et al. (2009) analyzed results on objective
neurocognitive feigning instruments in forensic neuropsychiatric patients and reported evidence for a dimensional
structure of the construct. Thus, at a fundamental level, the
categorical DSM criteria for malingering do not map on to
available objective data on the nature of the phenomenon.
The DSM conceptual model for malingering has been
criticized from other perspectives as well. Surveying the
criteria noted above whose presence was supposed to
increase suspicion of the presence of malingering, Rogers
(1990) argued that the only integrating theme was “badness” or a criminological model. As evidence of this,
Rogers suggested that the DSM criteria essentially characterize the malingerer as a “bad person” (antisocial personality disorder), in “bad circumstances” (legal difficulties),
doing “bad things” (uncooperative with evaluation and
treatment). Unlike other diagnoses, this conception of
malingering seems less related to a description of distinct
symptoms and behaviors and more related to a proscription
of one’s character.
In contrast, Rogers (1990) offered an “adaptational”
model, which views malingering as a reasoned response by
an individual facing adversarial circumstances with few
alternatives perceived to be available. This perspective
removes some of the moralistic baggage of the DSM
criteria and focuses on identification of the feigning
response to situations perceived to be challenging by the
patient. In this sense, recognition of feigned symptoms may
assist the clinician to understand basic anxieties (e.g., fear
of military service) or insecurities (e.g., limited financial
resources) that may in some circumstances benefit future
care. As Stone and Boone (2007, p. 11) state, “recognition
of feigning behaviors may prove to be the first therapeutic
step to understanding the patient’s actual needs.”
Another conceptual concern with the present DSM text
on malingering is the implied assumption that malingering
is monolithic and that malingerers will fake bad on most, if
not all of the procedures they undergo. In contrast to this
perspective, recent research has identified at least three
distinct targets for false symptoms, including psychiatric,
physical/somatic, and cognitive/neuropsychological feigning (Rogers 2008a, b). Evidence for at least partial
independence in two of these domains was reported by
Alwes et al. (2008), who administered objective tests for
feigned psychiatric symptoms and false neuropsychological
deficits to over 300 individuals undergoing forensic
neuropsychiatric evaluation. They reported that while the
base rate of probable psychiatric feigning was about 7.5%,
the prevalence of probable feigned neuropsychological
deficit was 24.4%, and only 13 patients met criteria for
probable feigning of both types of symptoms. Consistent
with this evidence for independence of feigned symptoms,
Nelson et al. (2007) factor analyzed MMPI-2 validity scales
and multiple neurocognitive feigning instruments from a
compensation-seeking traumatic brain injury sample. The
two domains of feigning detection indices loaded on
separate, distinct factors. The authors concluded that
“litigants and claimants can exhibit complex presentations
and unique forms of response bias (cognitive, psychological, or both)” (p. 447).
Practical Issues
A significant practical concern is that the text describing
malingering in DSM-III (American Psychiatric Association
2000) was barely changed 20 years later in DSM-IV-TR
(American Psychiatric Association 1980) and, as noted
above, apparently will not be updated in DSM-5. From a
scientific perspective, this is very troubling in light of the
fact that the literature on malingering has expanded
tremendously in the 30 years since the appearance of
DSM-III. Figure 1 shows the number of publications with
malingering as a keyword from 1980 to 2009. It can be
seen that at the time DSM-III appeared, only two or three
papers per year were published on malingering, whereas in
2009, the last year for which complete data were available,
there were more than 90 publications on this topic. In the
20 years between 1989 and 2009, over 1,200 papers on
malingering appeared (ISI Web of Science). In the 3 years
prior to preparation of this manuscript, four edited volumes
have been published on malingering (Boone 2007a, b;
Larrabee et al. 2007; Morgan and Sweet 2009; Rogers
2008a, b).
The exponential growth in malingering literature has
also supported development of several professional position
papers (e.g., AACN Board of Directors 2007; Bush et al.
2005; Heilbronner et al. 2009). These works offer empirically based, clinically relevant, and consensus-defined
recommendations related to the assessment and diagnosis
of malingering. It is regrettable that many professionals are
more inclined to consult these references than what is
meant to be the definitive reference tool in the practice of
mental health professions (i.e., DSM). In short, the failure
to update the criteria for malingering in DSM-5 ignores
more than 30 years of empirical and theoretical work on the
topic. The evolution of symptom validity and malingering
literature in recent decades has culminated in a sophisticated conception of malingering that essentially renders DSMIV-TR criteria obsolete.
Psychol. Inj. and Law
Fig. 1 Annual number of publications with keyword malingering from 1980 to 2009. Note: Image captured from ISI Web of Knowledge
In addition to the failure to incorporate more recent data
on the condition, the text guiding identification of malingering is problematic in clinical application as well. As
noted earlier, the key features of both the DSM-III and
DSM-IV-TR descriptions of malingering include (1) the
intentional (voluntary) production of false or grossly
exaggerated physical or psychological symptoms and (2)
motivated by external incentives (American Psychiatric
Association 1980, pp. 331–332; American Psychiatric
Association 2000, pp. 739–740). Considering the criterion
of intentionality, in the absence of a confession, or perhaps
a video recording performance of an act a patient claims to
be unable to carry out, it is difficult to discern an objective
procedure for meeting this prong. In fact, Erickson
(Pankratz and Erickson 1990) emphasizes that attributions
of intention, as required by the DSM criteria, are likely to
be highly speculative. Thus, the current framework for
identifying malingering virtually requires subjective determination of a key part of the diagnosis of this condition.
Turning next to external motivation as a requirement,
Boone 2007a, b points out that it is exceptionally difficult
to arrive at an objectively based discrimination between
externally motivated malingering and internally motivated
somatoform disorder. In fact, it seems likely that most
behaviors are driven by both intrinsic and extrinsic factors,
and once again, in the absence of honest self-report,
objective and validated methods for drawing this distinction
are lacking, leaving the other core aspect of DSM-defined
malingering also to be established by subjective means.
Given the severe consequences of a determination of
malingering in many circumstances such as civil and
criminal legal actions, it seems undesirable to base the
relevant criteria solely on clinical judgment, which has been
found unreliable in most studies of its accuracy rates (Garb
1998; Zimmerman 2003).
The DSM-IV-TR text on malingering has also proven
problematic in application in another important way. As
noted above, clinicians are directed to strongly suspect the
presence of malingering when two or more of four
conditions are met: medicolegal context of presentation,
marked discrepancy between claimed stress or disability
and objective findings, lack of cooperation in diagnostic
process and in compliance with treatment regimen, and
presence of antisocial personality disorder. Unfortunately,
Psychol. Inj. and Law
when Rogers (1990) evaluated the accuracy of these
criteria, correct classification rates were only 20%. Thus,
the screening criteria for malingering provided in DSM are
far too inaccurate to be used in clinical practice.
To summarize, the current DSM text on malingering is
terribly flawed on both conceptual and practical grounds.
This suggests that this V code should be replaced with a
more empirically supported alternative. With the goal of
moving toward such a replacement, current perspectives on
alternative models will be reviewed next.
Alternative Models for Identifying Malingering
In response to growing concerns about the difficulties in
implementing the recommendations of DSM for identifying
malingering, a number of alternative frameworks have been
proposed. These vary considerably in their complexity and
completeness. In recognition of the domain-specific nature
of malingering reviewed earlier, these will be presented in
separate sections addressing feigning of psychiatric, cognitive or neuropsychological, and physical or somatic
symptoms.
Detecting Feigned Psychiatric Symptoms
In an extensive research program, Richard Rogers has
explored conceptual models, detection strategies, and
classification accuracies for identifying feigned psychiatric
symptoms. One of his important points of clarification is
that tests and other objective procedures do not identify
malingering, as defined by DSM, but rather detect
fabricated or significantly exaggerated symptoms “without
any assumptions about… goals” (Rogers et al. 2010, p. 5).
Note that this focuses attention on objective documentation
of false symptom reports, without attempting to impute
volition or external goals. This sidesteps the seemingly
intractable problem of inferring motivation and volition
without validated, objective methods. At the time of this
writing, the final form of DSM-5 has not yet emerged.
However, it is possible that changes to the diagnostic
criteria for conversion disorder and factitious disorder may
mitigate the need to distinguish consciously determined
from unconsciously determined symptoms as well as to
discriminate internal from external goals.
Rogers (1990) provided an extensive review of strategies
for detecting feigned psychiatric symptom reports that had
appeared in the published literature. This early work was
updated in Rogers (2008a, b). Table 1 summarizes the
detection strategies he concluded were validated, as well as
objective scales from various instruments implementing
these approaches to detecting malingering. Rogers (2008a,
b) divides these into two broad categories: unlikely
presentations (first four strategies) and improbable symptoms (last five strategies). It is interesting to note that many
of these approaches to detecting feigned psychopathology
Table 1 Selected strategies for identifying feigned mental disorder
Strategy
Explanation
Scales
Rare symptoms
Symptoms rarely reported by genuine patients
Quasi-rare symptoms
Improbable symptoms
Symptom combinations
Indiscriminant endorsement of
symptoms
Severity of symptoms
Obvious symptoms
Reported vs. observed
symptoms
Erroneous stereotype
symptoms
Symptoms rarely reported by normals
Symptoms that are fantastic or absurd
Symptoms that are common but rarely occur together
Endorsement of excessive proportion of symptoms
MMPI-2 Fp, SIRS RS, PAI NIM,
M-FAST UH
MMPI-2F and Fb
SIRS IA, MCMI-III VI
SIRS SC, M-FAST RC
SIRS SEL
Excessive number of symptoms endorsed as unbearable or extreme
Excessive number of clear symptoms of mental disorder endorsed
Discrepancies between self-reported and observed symptoms
SIRS SEV, M-FAST ES
SIRS BL
SIRS RO, M-FAST RO
Endorsement of symptoms erroneously thought to be reported by
patients with mental disorders
MMPI-2 Ds, PSI EPS
Source: Rogers (2008a, b, pp. 19–21)
MMPI-2 Minnesota Multiphasic Personality Inventory 2nd Edition, Fp MMPI-2 Infrequency Psychopathology, F MMPI-2 Infrequency Scale, Fb
MMPI-2 Back Page Infrequency Scale, Ds MMPI-2 Dissimulation Scale, SIRS Structured Interview of Reported Symptoms, RS SIRS Rare
Symptoms Scale, IA SIRS Improbable or Absurd Scale, SC SIRS Symptom Combination Scale, SEL SIRS Symptom Selectivity Scale, SEV SIRS
Symptom Severity Scale, BL SIRS Blatant Symptom Scale, RO SIRS Reported vs. Observed Symptoms Scale, PAI Personality Assessment
Inventory, NIM PAI Negative Impression Management Scale, M-FAST Miller Forensic Assessment of Symptoms Test, UH M-FAST Unusual
Hallucinations Scale, RC M-FAST Rare Symptom Combination Scale, ES M-FAST Extreme Symptom Scale, RO M-FAST Reported vs.
Observed Symptoms Scale, MCMI-III Millon Clinical Multiaxial Inventory, 3rd Edition, VI MCMI-III Validity Index, PSI Psychological
Screening Inventory, EPS PSI Erroneous Stereotypes Scale
Psychol. Inj. and Law
have been endorsed in a more qualitative form by Resnick
and Knoll (2008), who review literature on detection of
malingered psychosis from the standpoint of forensic
psychiatry. For example, they endorse reviewing reports
of hallucinations and delusions from the perspective of
atypical content, unbearable severity, and inconsistency of
reported versus observed behavior.
As reviewed in Table 1, there are several instruments and
scales that allow objective detection of feigned symptoms,
including validity scales from the MMPI-2 (Butcher et al.
2001), MMPI-2-RF (Ben-Porath and Tellegen 2008),
Personality Assessment Inventory (Morey 2007), and the
Psychological Screening Inventory. Additionally dedicated
instruments validated for this purpose include the SIRS and
the Miller Forensic Assessment of Symptoms Test. The
varying operating characteristics of these instruments and
scales are reviewed by Berry et al. (2008). Thus, using
appropriate methods, it is possible to achieve reliable and
valid identification of false psychiatric symptom reports.
Consideration of the available literature on detection of
malingering suggests the following:
1. Focusing on objective identification of feigned psychiatric symptom reports, without attempting to infer
volition or motivation, may enhance the focus and
probably the accuracy of criteria.
2. Systematic review of the published literature on
techniques for detecting feigned psychiatric symptom
reports may yield useful recommendations for clinical
identification of this condition.
3. Employment of multiple strategies for identifying false
psychiatric symptom reports will likely increase accuracy of classification.
4. A focus on minimizing false-positive rates for any
single detection strategy may allow adequate sensitivity
to feigning with minimal cost in specificity when
multiple strategies are used.
Detecting Feigned Cognitive/Neuropsychological
Symptoms
Neuropsychologists and neuropsychiatrists often evaluate
patients with purported brain injuries in secondary gain
contexts, settings in which substantial benefits may be
attained by appearing more impaired than is in fact the case
(e.g., civil lawsuits, disability evaluations, competency to
stand trial, etc.). Clinicians working with this population
have long been dissatisfied with the DSM framework for
determining malingering. An immediate concern was that
the DSM criteria were apparently written primarily with
traditional psychiatric disorders in mind. Whereas feigning
a psychiatric disorder might involve complaints and
behaviors concerning a discrete set of signs and symptoms
during evaluation and observation, neuropsychologists and
clinical psychologists measure level of ability using
standardized tests of intelligence, memory, problem solving, and other areas of cognitive function.
Several early tests for malingered neurocognitive deficit
(MND) such as the Rey 15-Item Test were described in
Lezak’s influential text on neuropsychological assessment
(Lezak 1976). However, a major breakthrough occurred
with the adoption of forced-choice testing formats as
described by Binder and Pankratz (1987). Typically, this
involves posing a question or problem to a test-taker with
two answers to choose from. This approach means that the
probability of a correct response in the absence of any
preserved ability is 50%. Over a large number of trials, a
feigning patient may be clearly identified when he or she
scores statistically significantly below chance. Such a result
strongly implies that the test-taker knew the correct answer
and instead chose the incorrect alternative. Although early
work in this area used the conservative statistically significantly below chance criterion, studies using simulated
malingerers determined that only a fraction of instructed
feigners performed this poorly with any regularity (Guilmette
et al. 1993). Recently, Greve et al. (2009) confirmed this low
prevalence by reporting that statistically significantly below
chance performance occurred in only about 12% of over
1,000 forensic neuropsychological evaluees given multiple
symptom validity tests.
The low prevalence of statistically significantly below
chance performance by known feigners led to a move to
identify “norm-based” cutting scores, in which results from
large groups of patients with the disorder in question who
were not seeking compensation were used to set a “floor” on
expected performance from cooperative patients (Guilmette et
al. 1994). Compensation-seeking test-takers who scored
below this level but not statistically significantly below
chance were said to have invalid test data. Vickery et al.
(2001) meta-analytically reviewed several of these tests and
concluded that, on average, they were moderately sensitive
and highly specific for the detection of feigned neuropsychological impairments.
There are now a large number of well-validated tests for
detection of feigned cognitive deficits. Grote and Hook
(2007) reviewed several of the most widely studied
procedures. They drew generally positive conclusions about
many of these instruments, which included the Computerized Assessment of Response Bias, the Portland Digit
Recognition Test, Test of Memory Malingering, Victoria
Symptom Validity Test, Medical Symptom Validity Test,
Letter Memory Test, Word Memory Test, and Validity
Indicator Profile.
After reasonably accurate tests for feigned neuropsychological deficits appeared, attention turned to providing a
framework for diagnosing MND. Early researchers (e.g.,
Psychol. Inj. and Law
Greiffenstein et al. 1994; Nies and Sweet 1994) provided
preliminary suggestions for detection of cognitive malingering. However, the system that has proven the most influential
in this area to date has been that proposed by Slick et al.
(1999). Table 2 provides a summary of the framework.
Using these criteria, Slick et al. (1999) went on to
propose diagnostic categories for MND. These were
definite, probable, and possible MND, as follows:
Definite MND
one type of evidence from neuropsychological testing
and one type of evidence from self-report (B and C)
3. Behaviors from group B and C are not fully
accounted for by other factors (D)
Possible MND
1. Presence of substantial external incentive (A)
2. One or more types of evidence from self-report (C)
3. Behaviors from group B and C are not fully
accounted for by other factors (D)
1. Presence of a substantial external incentive (A)
2. Definite negative response bias (statistically significantly below chance performance) (B)
3. Behaviors from group B are not fully accounted for
by other factors (D)
Probable MND
Although suggestions for improving this system have
appeared (Boone 2007a, b; Larrabee et al. 2007), it has been
widely used in published research on the detection of
feigning during neuropsychological examinations. This
system also may provide useful insights into revision of
the DSM framework for identifying malingering, as follows:
1. Presence of a substantial external incentive (A)
2. Two or more types of evidence from neuropsychological testing excluding definite response bias (B) (or)
1. When forced-choice neuropsychological tests are used, it
is possible to identify an objective threshold that strongly
implies deliberate choice of incorrect answers (e.g.,
statistically significantly below chance performance) that
is perhaps the most compelling evidence for feigning.
2. Criteria for identifying feigned symptoms may need to
be modified depending on the specific type of symptom
or impairment that is involved (e.g., false psychiatric
versus cognitive/neuropsychological symptoms).
3. Consideration of the quality and magnitude of evidence
for false symptom reports may guide assignment of
certainty levels for the presence of feigning, such as
possible, probable, or definite.
4. It is possible to provide a framework for identifying the
presence of feigned neuropsychological deficits that
relies primarily on well-validated, objective tests.
5. It is possible to chain results from multiple forcedchoice tests to provide a probability of feigning using
several different approaches, as described by Larrabee
(2007a, b, c, pp. 14–26).
Table 2 Summary of diagnostic criteria for malingered neurocognitive dysfunction
Criterion A
Presence of a substantial external incentive
Example: disability pension, civil lawsuit for damages, etc.
Criterion B
Evidence from neuropsychological testing
Example: performance statistically significantly below chance on
forced-choice testing
(or) Performance below cutting scores on well-validated tests of
cognitive feigning
(or) Discrepancy between test data and known patterns of brain
functioning
(or) Discrepancy between test data and observed behavior
(or) Discrepancy between test data and reliable collateral reports
(or) Discrepancy between test data and documented background
history
Criterion C
Evidence from self-report
Example: self-reported history is discrepant with documented history
(or) Self-reported history is discrepant with known patterns of brain
functioning
(or) Self-reported symptoms are discrepant with behavioral observations
(or) Self-reported symptoms are discrepant with data from collateral
informants
(or) Evidence from self-report inventories of exaggeration or
fabrication of psychological dysfunction
Criterion D
Behaviors meeting criteria B or C are not fully accounted for by
psychiatric, neurological, or developmental factors
Example: psychosis, mental retardation, etc.…
Source: Slick et al. (1999)
Detecting Feigned Physical or Somatic Symptoms
It is perhaps unsurprising that it is in the area of objective
detection of feigned physical or somatic symptoms that
mental health professionals have made the least progress,
though Heilbronner et al. (2009) offer suggestions for
symptom validity assessment in this area and directions for
future study. It should be noted that various medical
specialties have procedures for detection of feigned
physical symptoms; Granacher has described these as
“detection methods employed by physicians (that) are part
of the art of medicine; they are based on the identification
of nonanatomical or non-physiological presentations of
apparent neurological and physical disorders” (Granacher
and Berry 2008, p. 149). Lanyon (1978) included a health
Psychol. Inj. and Law
symptom overreporting scale on the Psychological Screening Inventory. Although some attention has been devoted to
detecting feigned somatic symptoms on the MMPI-2
(Larrabee 2003, 2007a, b, c; Bianchini et al. 2008) and
MMPI-2-RF (Wygant et al. 2009), much of the work in this
broad area by mental health professionals has involved
identification of feigned pain symptoms. Drawing on Slick
et al. (1999), Bianchini et al. (2005) proposed a diagnostic
framework for identifying malingered pain-related disability, as outlined in Table 3. These authors also grade the
malingered pain-related disability into possible, probable,
or definite with increasingly stringent requirements.
Table 3 Selected proposed criteria for the diagnosis of malingered
pain-related disability
Criterion A: evidence of significant external incentive
Example: personal injury settlement, disability pension, evasion of
criminal prosecution, etc.
Criterion B: evidence from physical evaluation
Example: performance on one or more well-validated measures of
physical capacity (e.g., Jamar Grip Test) is consistent with
exaggeration of diminished physical capacity
(or) Discrepancy between self-report of pain and physiological
reactivity
(or) Physical examination or functional capacity evaluations reveal
behaviors in consistent with known physiological mechanisms (e.g.,
Waddell’s signs)
(or) Discrepancy between the patient’s capacities during examination
and when he or she is unaware of observation
Criterion C: Evidence from neuropsychological testing
Example: significantly below chance performance on one or more
well-validated tests designed to measure exaggeration or fabrication
of neuropsychological deficit
(or) Performance below cutoffs on one or more established wellvalidated tests designed to measure exaggeration or fabrication of
neuropsychological deficit
(or) Discrepancy between neuropsychological test data and known
patterns of brain functioning
(or) Discrepancy between data from two or more neuropsychological
tests and observed behavior
Criterion D: evidence from self-report
Example: compelling inconsistency between patient presentation
while being evaluated and when he or she is unaware of being
observed
(or) Self-reported history is discrepant with documented history
(or) Self-reported symptoms are inconsistent with known patterns of
physiological or neurological functioning
(or) Self-reported symptoms are discrepant with observations of
behavior.
(or) Evidence from self-report psychological tests of exaggeration or
fabrication of complaints
Criterion E: behavior meeting criteria from B, C, and D is not fully
accounted for by psychiatric, neurological, or developmental factors
Source: Bianchini et al. (2005)
Finally, they also recommend employing multiple strategies for identifying feigned pain symptoms.
Integration of Models for Detecting Feigned Symptom
Reports
Consideration of these three alternative models leads to
several suggestions that might usefully be incorporated in a
revised text for DSM-5. First, when substantial incentives
are present for successful faking, it would be helpful to
focus on identification of feigned symptoms without
attempting to infer conscious intent or intended goal of
the patient. As reviewed earlier, there are very few
procedures or situations in which objective determination
of volition or intent may be determined (even in the case of
statistically significantly below chance performance on
forced-choice tests, only a small minority of known
feigners breaches this threshold). Therefore, the DSM-5
text should focus on identification of feigned symptoms,
rather than malingering as previously defined.
Another conclusion from considering the alternative
models is to acknowledge that feigned symptoms may take
many forms. Thus, specifiers, such as psychiatric, cognitive/neuropsychological, or somatic/physical, should be
included in a determination of feigned symptoms. It seems
likely that additional potential foci for false reports may be
identified, and these could be added as specifiers as the
research literature grows.
A third area involves the need to employ multiple
strategies for documenting the presence of feigned symptoms. This can be seen in the strategies for detecting
feigned symptoms outlined by Rogers (2008a, b) and
reviewed earlier, such as improbable or absurd symptoms,
symptom combinations, reported versus observed symptoms, etc. In the Slick et al. (1999) and Bianchini et al.
(2005) frameworks, this is illustrated by requiring documentation of feigning from both neuropsychological testing
and self-report in order to identify probable feigning.
Wherever possible, these criteria should be met using
standardized, objective measures, although behavioral
observations by two or more individuals or video recordings could also establish evidence of feigning. Cutting
scores for standardized scales for determining feigned
symptoms, particularly if multiple scales are involved,
should be selected to minimize false-positive results. In
this regard, symptom validity tests typically set cutting
scores that hold false-positive rates at 5–10%.
In recognition of the varying levels of certainty for
identifying feigned symptoms, a hierarchy of possible,
probable, and definite modifiers seems appropriate. Of
course, depending on the nature of the false symptoms, it is
likely that operationalization of these modifiers will need to
be tailored to each category. For example, using forced-
Psychol. Inj. and Law
choice cognitive tests, statistically significantly below
chance performance is a useful and objective means of
documenting definite feigning of cognitive/neuropsychological symptoms. At present, similar objective procedures
may not be available for false psychiatric symptoms.
However, video recording of a defendant who claims
psychosis interacting normally with peers might achieve
the level of definite feigned psychiatric symptoms.
Finally, false symptom reports could be graded by
severity into mild, moderate, or severe ranges. This could
be accomplished by considering the difference between
claimed disability and actual functioning, or perhaps by
the magnitude of the feigned deficits. This would address
the apparent dimensional nature of feigning as reviewed
earlier.
In summary, the present DSM criteria for identifying
malingering are badly flawed at both conceptual and
practical levels. Given the availability of successful models
for detecting feigning of psychiatric, cognitive/neuropsychological, and somatic/physical symptoms, the DSM text
on malingering should be replaced by empirically based
criteria for detecting false symptom reports. Deletion of the
requirement for usually subjective judgments of uncertain
validity about volition and intent is recommended. Replacement text regarding identification of feigned symptoms using well-validated, objective techniques can be
based on published research and divided into feigned
psychiatric, cognitive/neuropsychological, or somatic/physical symptoms. Certainty about the presence of feigned
symptoms could be graded into possible, probable, or
definite categories. Lastly, in recognition of the apparent
dimensional nature of feigning, ratings of mild, moderate,
or severe could be operationalized. This proposed revision,
while requiring further fleshing out for clinical application,
could do much to address the weaknesses of the current
DSM text on malingering and be of great potential benefit
to clinicians working with patients who have substantial
incentives for exaggerating or fabricating symptoms.
References
Alwes, Y. R., Clark, J. A., Berry, D. T. R., & Granacher, R. P. (2008).
Screening for feigning in a civil forensic setting. Journal of
Clinical and Experimental Neuropsychology, 30, 1–8.
American Academy of Clinical Neuropsychology (AACN) Board of
Directors. (2007). American Academy of Clinical Neuropsychology (AACN) practice guidelines for neuropsychological assessment and consultation. The Clinical Neuropsychologist, 21, 209–
231.
American Psychiatric Association. (1980). Diagnostic and statistical
manual of mental disorders (3rd ed.). Washington, D.C.: Author.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders, 4th Ed., text revision. Washington,
D.C.: Author.
Ben-Porath, Y. S., & Tellegen, A. (2008). MMPI-2-RF: Manual for
administration, scoring and interpretation. Minneapolis: University of Minnesota Press.
Berry, D. T. R., Sollman, M. J., Schipper, L. J., Clark, J. A., &
Shandera, A. L. (2008). Assessment of feigned psychological
symptoms. In J. Butcher (Ed.), Oxford handbook of personality assessment (pp. 613–642). New York: Oxford University
Press.
Bianchini, K. J., Greve, K. W., & Glynn, G. (2005). On the diagnosis
of malingered pain-related disability: Lessons from cognitive
malingering research. The Spine Journal, 5, 404–417.
Bianchini, K. J., Etherton, J. L., Greve, K. W., Heinly, M. T., &
Meyers, J. E. (2008). Classification accuracy of MMPI-2 validity
scales for the detection of pain-related malingering: A known
groups study. Assessment, 15, 435–449.
Binder, L. M., & Pankratz, L. (1987). Neuropsychological evidence of
a factitious memory complaint. Journal of Clinical and Experimental Neuropsychology, 9, 167–171.
Boone, K. B. (Ed.). (2007a). Assessment of feigned cognitive
impairment: A neuropsychological perspective. New York:
Guilford.
Boone, K. B. (2007b). A reconsideration of the Slick et al. (1999)
criteria for malingered neurocognitive disorder. In K. B. Boone
(Ed.), Assessment of feigned cognitive impairment: A neuropsychological perspective (pp. 29–49). New York: Guilford.
Bush, S. S., Ruff, R. M., Troster, A., Barth, J. T., Koffler, S. P., et al.
(2005). NAN position paper: Symptom validity assessment:
Practice issues and medical necessity. Archives of Clinical
Neuropsychology, 20, 419–426.
Butcher, J. N., Graham, J. R., Ben-Porath, Y. S., Tellegen, A.,
Dahlstrom, W. G., & Kaemmer, B. (2001). MMPI-2: Manual for
administration, scoring and interpretation. Minneapolis: University of Minnesota Press.
Garb, H. N. (1998). Studying the clinician: Judgment research and
psychological assessment. Washington, D.C.: American Psychiatric Association.
Granacher, R. P., & Berry, D. T. R. (2008). Feigned medical
presentations. In R. Rogers (Ed.), Clinical assessment of
malingering and deception (3rd ed., pp. 145–156). New York:
Guilford.
Greiffenstein, M. F., Baker, W. J., & Gola, T. (1994). Validation of
malingered amnesia measures with a large clinical sample.
Psychological Assessment, 6, 218–224.
Greve, K. M., Binder, L. M., & Bianchini, K. J. (2009). Rates of
below chance performance in forced-choice symptom validity
tests. The Clinical Neuropsychologist, 23, 534–544.
Grote, C. L., & Hook, J. N. (2007). Forced-choice recognition tests of
malingering. In G. J. Larrabee (Ed.), Assessment of malingered
neuropsychological deficits (pp. 44–79). New York: Oxford
University Press.
Guilmette, T. J., Hart, K., & Guiliano, A. (1993). Malingering
detection: The use of a forced-choice method in identifying
organic versus simulated memory impairment. The Clinical
Neuropsychologist, 7, 59–69.
Guilmette, T. J., Hart, K., Guiliano, A., & Leininger, B. (1994).
Detecting simulated memory impairment: comparison of the
Rey-15-item test and the Hiscock forced-choice procedure. The
Clinical Neuropsychologist, 8, 283–294.
Heilbronner, R. L., Sweet, J. J., Morgan, J. E., Larrabee, G. J., Millis,
S. R., & Conference Participants (Nelson, N. W., et al.). (2009).
American Academy of Clinical Neuropsychology consensus
conference statement on the neuropsychological assessment of
effort, response bias, and malingering. The Clinical Neuropsychologist, 23, 1093–1129.
Lanyon, R. I. (1978). Psychological screening inventory: Manual (2nd
ed.). Port Huron: Research Psychologists.
Psychol. Inj. and Law
Larrabee, G. J. (2003). Exaggerated pain reports in litigants with
malingered neurocognitive dysfunction. The Clinical Neuropsychologist, 17, 395–401.
Larrabee, G. J. (Ed.). (2007a). Assessment of malingered neuropsychological deficits. New York: Oxford University Press.
Larrabee, G. J. (2007b). Refining diagnostic criteria for malingering. In
G. J. Larrabee (Ed.), Assessment of malingered neuropsychological
deficits (pp. 334–371). New York: Oxford University Press.
Larrabee, G. J. (2007c). Evaluation of exaggerated health and injury
symptomatology. In G. J. Larrabee (Ed.), Assessment of malingered neuropsychological deficits (pp. 264–286). New York:
Oxford University Press.
Larrabee, G. J., Greiffenstein, M. F., Greve, K. W., & Bianchini, K. J.
(2007). Refining diagnostic criteria for malingering. In G. J.
Larrabee (Ed.), Assessment of malingered neuropsychological
deficits (pp. 334–371). New York: Oxford University Press.
Lezak, M. D. (1976). Neuropsychological assessment. New York:
Oxford University Press.
Morey, L. C. (2007). Personality assessment inventory: Professional
manual (2nd ed.). Odessa: Psychological Assessment Resources.
Morgan, J. E., & Sweet, J. J. (2009). Neuropsychology of malingering
casebook. New York: Psychology.
Nelson, N. W., Sweet, J. J., Berry, D. T. R., Bryant, F. B., &
Granacher, R. P. (2007). Response validity in forensic neuropsychology: Exploratory factor analytic evidence of distinct cognitive and psychological constructs. Journal of the International
Neuropsychological Society, 13, 440–449.
Nies, K. J., & Sweet, J. J. (1994). Neuropsychological assessment and
malingering: A critical review of past and present strategies.
Archives of Clinical Neuropsychology, 9, 501–552.
Online Etymology Dictionary. (2010). Retrieved September 9, 2010
from http://www.etymonline.com/index.php?term=malinger.
Pankratz, L., & Erickson, R. C. (1990). Two views of malingering.
The Clinical Neuropsychologist, 4, 379–389.
Resnick, P. J., & Knoll, J. L. (2008). Clinical assessment of malingering
and deception (3rd ed., pp. 51–68). New York: Guilford.
Rogers, R. (1990). Models of feigned mental illness. Professional
Psychology, 21, 182–188.
Rogers, R. (2008a). Clinical assessment of malingering and deception
(3rd ed.). New York: Guilford.
Rogers, R. (2008b). Detection strategies. In R. Rogers (Ed.), Clinical
assessment of malingering and deception (3rd ed., pp. 14–38).
New York: Guilford.
Rogers, R., Sewell, K. W., & Gillard, N. D. (2010). Structured
interview of reported symptom professional manual. Odessa:
Psychological Assessment Resources.
Slick, D. J., Sherman, E. M. S., & Iverson, G. L. (1999). Diagnostic
criteria for malingered neurocognitive dysfunction: Proposed
standards for clinical practice and research. The Clinical
Neuropsychologist, 13, 545–561.
Stone, D. C., & Boone, K. B. (2007). Feigning of physical,
psychiatric, and cognitive symptoms. Examples from history,
the arts, and animal behavior. In K. B. Boone (Ed.), Assessment
of feigned cognitive impairment: A neuropsychological perspective (pp. 29–49). New York: Guilford.
Vickery, C. D., Berry, D. T. R., Inman, T. H., Harris, M. J., & Orey, S.
A. (2001). Detection of inadequate effort on neuropsychological
testing: A meta-analytic review of selected procedures. Archives
of Clinical Neuropsychology, 16, 45–73.
Walters, G. D., Rogers, R., Berry, D. T. R., Miller, H. A., Duncan, S.
A., McCusker, P. J., et al. (2008). Malingering as a categorical or
dimensional construct: The latent structure of feigned psychopathology as measured by the SIRS and MMPI-2. Psychological
Assessment, 20, 238–247.
Walters, G. D., Berry, D. T. R., Lanyon, R., & Murphy, M. (2009).
Are exaggerated health complaints continuous or categorical? A
taxometric analysis of the health problem overstatement scale.
Psychological Assessment, 21, 219–226.
Walters, G. D., Berry, D. T. R., Rogers, R., Payne, J. W., & Granacher,
R. P. (2009). Feigned neurocognitive deficit: Taxon or dimension? Journal of Clinical and Experimental Neuropsychology, 31,
584–593.
Wygant, D. B., Ben-Porath, Y. S., Arbisi, P. A., Berry, D. T. R.,
Freeman, D. B., & Heilbronner, R. L. (2009). Examination of the
MMPI-2 Restructured Form (MMPI-2-RF) validity scales in civil
forensic settings: Findings from simulation and known group
samples. Archives of Clinical Neuropsychology, 24, 671–680.
Zimmerman, M. (2003). What should the standard of care for
psychiatric diagnostic evaluations be? The Journal of Nervous
and Mental Disease, 191, 281–286.